Provider Demographics
NPI:1275212722
Name:CLARK, CALISTA
Entity Type:Individual
Prefix:
First Name:CALISTA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WV
Mailing Address - Zip Code:25247-0384
Mailing Address - Country:US
Mailing Address - Phone:937-418-7890
Mailing Address - Fax:
Practice Address - Street 1:108 CIERRA DR
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WV
Practice Address - Zip Code:25247-7708
Practice Address - Country:US
Practice Address - Phone:937-418-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker